Summary of this article
A Special Operations Group probe has uncovered a multi-crore fraud in the Rajasthan Government Health Scheme.
A nexus of doctors and lab operators allegedly raised fake, inflated diagnostic bills, including MRI scans, without examining patients.
The scam, involving forged prescriptions and altered reports uploaded to the RGHS portal, has drained public funds, defeating the scheme's purpose.
The Special Operation Group (SOG) in Rajasthan has busted a fraud within the Rajasthan Government Health Scheme (RGHS), a state-run public healthcare scheme. The scam, allegedly, caused financial loss worth crores to the state exchequer. SOG found the involvement of a coordinated network of medical professionals (doctors), and diagnostic centres. The irregularities were discovered during a broader probe into RGHS implementation.
The police have arrested one doctor (Dr Kamal Kumar Agrawal, associate professor of Orthopaedics, SK Hospital in Sikar) and a lab operator (Dr Banwari Lal, a private laboratory operator), according to the PTI. These individuals, according to officials, have manipulated the system by prescribing unnecessary and expensive diagnostic tests, such as MRI scans.
The investigation found that the accused had not examined the patients ever, but had raised the bills fraudulently. In many cases, patients have been prescribed the tests while such patients were entirely absent from the facility.
Reportedly, the fake tests and fraudulent practices were carried out through a nexus of doctors and lab operators who generated fake prescriptions and forged diagnostic reports to claim reimbursement of the cost from the state government. As a modus operandi, fake tests were falsely billed. For instance, a standard MRI test was billed as a contrast MRI test, which is a more expensive test, to claim a higher value. In other cases, multiple reports were generated from a single test to enhance the gains.
Further, the date of the report was also altered to claim funds for a patient who hadn’t even visited the city (Sikar) on that day. And, in some cases, the referrals issued by private doctors were manipulated to make them look like they came from government doctors, so as to enable them to claim the reimbursement.
Once a fake document report was ready, the accused would upload the fake documents directly to the RGHS portal to claim reimbursement.
According to the Additional Director General of Police (SOG) Vishal Bansal, the fraudulent practices have not only caused a significant financial loss but also affected the genuine and needy beneficiaries. While the SOG continues the probe to identify if more staff were involved, the state health department has initiated strict legal action against the accused to ensure accountability.
What Is The RGHS Scheme?
Rajasthan Government Health Scheme (RGHS) is a state government initiative for the general public, government officials, ministers, and state autonomous bodies to provide them with free and accessible healthcare.
What Does The RGHS Scheme Offer?
It offers the beneficiaries a cashless medical facility for the entire cycle of medical emergency and Outpatient Department (OPD), In-Patient Department (IPD), Day Care, maternity, and Child care facility, as per the Central Government Health Scheme (CGHS) package rates and the applicable medical rules for the respective RGHS category.
Who Is Eligible For The RGHS Scheme?
For RGHS beneficiaries, especially the serving and retired employees in state autonomous bodies, a sum insurance of Rs 5 lakhs (Rs 20,000 OPD inclusive) is provided per family per year, with an extra Rs 5 lakhs coverage per family per year for any catastrophic illness as specified within the scheme.
